Download Patient History

(888) 557-4448 | stahlny.com | Garden City | Manhattan | Hauppauge
Marc Werner, M.D. | Thierry Hufnagel, M.D. | Benjamin Chang, M.D.
Welcome! Please complete this form and return it to the receptionist so we may prepare your chart.
patient information
Last Name:
First Name:
MI:
DOB:
SS#:
Bill to same name: Y N
Age:
Date:
City:
State:
Zip:
Email Address (to receive our newsletter):
Home Phone:
Sex: M F
Street Address:
Employer:
Occupation:
Employer Phone:
Name of Nearest Relative:
Phone:
Whom may we thank for referring you to us (Name & Address):
race, ethnicity and preferred language
Race: ❑ American Indian ❑ Asian ❑ Black ❑ Native Hawaiian ❑ Type-Unkown ❑ White
Preferred Language:
Ethnicity: ❑ Hispanic ❑ Non-Hispanic ❑ Type-Unkown
Medicare #:
insurance information
Medicaid #:
Is Medicare your secondary payer as a result of TEFRA? Y N
Are you currently a member of an HMO, HIP or other managed care plan? Y N
Private Insurance Name:
Insured’s DOB:
primary insurance
Insured’s Name:
Insured’s SS#:
ID#:
Private Insurance Name:
Insured’s DOB:
ID#:
Relationship: Self Spouse Child Other
Group:
secondary insurance
Insured’s Name:
Insured’s SS#:
Relationship: Self Spouse Child Other
Group:
payment of benefits directly to the physician
I request that payment of authorized benefits be made directly to Stahl Eyecare Experts on my behalf for services furnished to me by the physician.
I authorize any holder of medical information about me to release to the Health Care Financing Administration and/or agent any information needed
to determine these benefits or the benefits payable for related services.
Signature:
Date:
Please turn over and fill out the other side of this form ➔
patient medical information
Diabetes
N Y
Last Blood Sugar:
Taken When?:
Last Hemoglobin AIC:
Taken When?:
Asthma
N Y
For ______ Years
Well controlled on medication?
N Y
High Blood Pressure
N Y
For ______ Years
Well controlled on medication?
N Y
Glaucoma
N Y
For ______ Years
Well controlled on medication?
N Y
Heart Attack
N Y
# of attacks: _____
What year was the last one?
Stroke
N Y
# of stokes: ______
What year was the last one?
High Cholesterol
N Y
Arthritis
N Y
Heart Disease
N Y
Cancer
N Y
Bronchitis
N Y
Emphysema
N Y
Smoking
❑ Current Every Day Smoker ❑ Current Some Day Smoker
❑ Former Smoker ❑ Unkown If Ever Smokeed
❑ Never Smoker
Other (Please list):
Medications
List any medications you are allergic to:
Eye medications you are taking:
Other medications that you are taking:
Eye History
When was your last eye examination?
Have you had any surgery performed on your eyes?
N Y If yes, for ____________________________
Do you wear glasses? N Y
Glasses are ______ years old.
If yes, for
Distance
Reading Only
Do you wear contact lenses? N Y
Bifocals
If yes,
Progressive Bifocals
Hard Soft
Wearing for ______ years.
What is the main problem that you are having with your eyes that you are here for today?
I am interested in the following
❑ LASIK (Laser Vision Correction)
❑ Botox® Cosmetic
❑ Other Cosmetic Procedures
primary care physician/family doctor
Name:
Address:
Do you want us to send a letter of your findings to this doctor?: Y N
Type: